Evolving Roles of the Medical Transcriptionist

Much has been discussed when it comes to the role of a certified medical transcriptionist in today’s electronic healthcare environment. However, the Bureau of Labor and Statistics and other watchers within the industry predict that healthcare documentation is here to stay.

How it changes and unfolds in the future is in large part dependent upon technological advances, but it is equally dependent upon the dedicated and proficient medical record facilitators of the future.

What is a medical transcriptionist?

In simplest terms, a medical transcriptionist (MT) is a highly-skilled allied health professional who transcribes and/or verifies the spoken or written dictation by a healthcare professional into a medical report. This report then becomes part of the permanent health story of a patient, his or her medical record.

However, as healthcare information technology (HIT) has begun to change, the role of the MT has changed with it. As of late 2013, medical transcription credentials have been re-branded to more accurately depict what an MT does. This in effect further illuminates the critical role of this position for accurate medical report capture.

What is a healthcare documentation specialist?

Medical transcriptionists are now referred to as healthcare documentation specialists, which better defines what transcriptionists do every day. Now, they concisely and precisely confirm information entered into the medical records of individual patients and identify discrepancies and inaccuracies.

In effect, healthcare documentation specialists are becoming auditors of each medical report. In light of the electronic age, where a single generated medical report’s information is used to populate numerous entries across multiple specialties within a huge network, it’s easy to understand the vital nature of this expertise.

The new credentials RHDS (registered healthcare documentation specialist) and the CHDS (certified healthcare documentation specialist) are achieved by formal testing through AHDI (Association for Healthcare Documentation Integrity). These have formally replaced the RMT and the CMT (registered medical transcriptionist and certified medical transcriptionist, respectively). The new designations clearly define the skill set formerly associated with an MT, thus elevating it to a higher level.

Why are MTs and HDSs needed in medicine?

There are many critical roles in the medical field, and each requires its own level of expertise and medical transcription training. One is no less valuable than the other. The sum of the parts equals the whole.

Without accurate documentation in a patient’s healthcare record, physicians and providers cannot prescribe medication accurately, note chronic diseases and conditions, or remember every detail of a patient’s history. Whether the records are in paper or electronic form, this documentation will always be a necessary part of the medical record.

How are roles changing for MTs?

As more and more electronic methods are used, such as speech recognition technology (SRT), MTs have naturally risen to the forefront of healthcare information technology. As physicians scramble to learn electronic health record (EHR) systems, MTs are well-equipped to create and use templates for reports, resolve discrepant patient names and numbers, and spot incorrect medications and/or dosages. These are just the most critical areas of error that an MT with solid medical transcription training would be able to identify and correct.

Other evolving roles are medical record abstractors, speech recognition editors, chart analysts and EHR facilitators. Speech recognition editors are in huge demand. Especially, those who have the ability to decipher the “word salad” created by speech engines and create accurate records of patient encounters by comparing the digital voice file to the electronic version.

Some MTs use medical transcription to springboard careers into medical billing and coding, medical scribe programs, quality assurance (QA) editors and supervisory positions, as well as EHR managers.

Another role of the knowledgeable MT is in direct patient care as a medical records advisor, who helps patients or families decipher their medical records and/or correcting inaccuracies. This is becoming an in-demand profession as more critical patient safety errors are being found in medical records as evidenced by the Your Record Speaks campaign.

What’s the future for medical transcription?

In the next decade, it is projected that the demand for qualified HDSs will increase dramatically, in spite of the electronic medical record. This is because there are so many baby boomers, who are currently at or near retirement age (which translates to more patients needing medical care).

Along with this aging population increase, comes the retirement of many from the MT field. It’s predicted that this will cause an unusual shift in the workforce generating an overwhelming need for qualified MTs. This, plus the changing roles coupled with the electronic health record, will push that need up even further.

Audrey Kirchner is a Certified Healthcare Documentation Specialist (CHDS). She has been in the medical transcription (MT) profession for about 40 years. In 1989, she started and operated her own medical transcription service. She has also worked as a top medical transcription quality assurance editor for Nuance, the largest MT service in the world.
Aside from being an MT instructor, Audrey's part of six committees at the Association for Healthcare Documentation Integrity (AHDI) and is currently the Director of Finance for the AHDI-West component. She helped rewrite the curriculum for the new credentials (RHDS and CHDS) and was the first member of AHDI to achieve the new credential.
She is passionate about medical transcription, because it has been her life's work. Audrey is also an online freelance writer. She has published several books and has written multiple articles for the magazine Plexus – published by the AHDI.